The New World of SNF Reimbursement - PDPM

1 The New World of SNF Reimbursement - PDPM. Michelle Gale-Nelson, RN, MSN, MBA, RAC-CT, DNS-CT. Cambridge Healthcare Services Buena Park, CA. 1. Disclosures I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services 2. Learning Objectives Identify the 6 main components of the PDPM payment model Understand the importance of accurate diagnosis selection in Section I of the MDS. Determine how the new payment model will impact the SNF Reimbursement process 3. Acronyms Used ARD Assessment Reference Date (MDS).

2 IPA Interim Payment Assessment MDS Minimum Data Set NPE End of PPS Stay (MDS). PDPM - Patient Driven Payment Model PPS Prospective Payment System QRP Quality Reporting Program RAI Resident Assessment Instrument (aka: MDS Manual). RUGs Resource Utilization Group(s). SNF Skilled Nursing Facility 4. PDPM Overview CMS revised the proposed rule from RCS-1 to PDPM in May of 2018. Implementation Date October 1, 2019 or Fiscal Year 2020. 6 components generate the residents' daily reimbursed rate Daily rate drops 2% each day after day 21 of a covered stay October 1 MDS item set changes correlate to PDPM.

3 Reimbursement changes Decreases the number of PPS MDS assessments needed but adds the IPA MDS assessment 5. 6 Components of PDPM. Four Case-Mix Components Physical & Occupational Therapy (2). Speech Language Pathology Skilled Nursing Services (RUGs IV). Non-Therapy Ancillary Services One Non-Case-Mix Component 6. Therapy Services PDPM first uses the resident's clinical conditions to determine therapy payment categories Therapy minutes/days provided does not weigh into the PDPM calculation Functional scores from section GG of the MDS are used to adjust the case-mix 7.

4 PT/OT Components Both therapy disciplines use the same scoring methodology: 1. A residents' clinical condition (MDS item I8000) is assessed upon admission (MDS 5 day assessment). +. 2. A resident's performance scores from selected MDS. section GG items as determined on their 5 day MDS. assessment 8. PT/OT Components-GG. GG0130A1 (Eating). GG0130B1 (Oral Hygiene). GG0130C1 (Toileting Hygiene). GG0170B1 (Sit to Lying). GG0170C1 (Lying to Sitting on Side of Bed). GG0170D1 (Sit to Stand). GG0170E1 (Chair/Bed-to-Chair). GG0170F1 (Toilet Transfer). GG0170J1 (Walk 50 Feet with Two Turns).

5 GG0170K1 (Walk 150 Feet). 9. PT/OT Components-GG. 10. PT/OT Components-GG. 11. PT/OT Components-GG. 12. Speech & Language Pathology Component Different scoring method from PT/OT. 1. A residents' clinical condition (MDS item I8000) is assessed upon admission (MDS 5 day assessment). and coded as an Acute Neurological Condition +. 2. Cognitive Impairments are determined (MDS BIMS. Score) +. 3. Comorbidities (CVA, TIA, Stroke, Apraxia, etc.) +. 4. Swallowing problems (MDS items K0100 A-D) and/or a mechanically altered diet (MDS item K0510C). 13. Skilled Nursing Component 25 existing RUGs IV nursing groups with 6 major categories: Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Functioning 14.

6 Skilled Nursing Component, cont'd. Depression symptoms (MDS Section D, PHQ-9). adjusts the case-mix index score Restorative Nursing services (MDS Section O), further adjusts the case-mix index score 18% add-on for HIV/AIDS residents 15. Non-Therapy Ancillary Component Information for payment is derived from SNF claims data and MDS items in sections H, I, K, M, and O (see next slides). 16. Non-Therapy Ancillary Component SNF Claims Data HIV/AIDS. MDS Sections H and K. Ostomy (H0100C). Intermittent Catheterization (H0100D). Parenteral IV Feeding-TPN (K0510A2 & K0710A2).

7 Feeding Tube (K0510B2). 17. Non-Therapy Ancillary Component MDS Sections M and O. Diabetic Foot Ulcer (M01040B). Stage IV Pressure Ulcer (M0300D1). Other Foot/Skin Problems (M01040A & M01040C). IV Medication (O0100H2). Ventilator/Respirator (O0100F2). Transfusion (O0100I2). Tracheostomy (O0100E2). Infection Isolation (O0100M2). Radiation (O0100B2). Suctioning (O0100D2). 18. Non-Therapy Ancillary Component MDS Section I. Infection with Multiple Resistant Drug Organism (I7000). Multiple Sclerosis (I5200). Asthma, COPD, or Chronic Lung Disease (I6200). Diabetes Mellitus (I2900).

8 Wound Infection (other than to foot) (I2500). Malnutrition (I5600). 19. Non-Therapy Ancillary Component MDS Section I: Additional Active Diagnoses I8000. Lung Transplant Status Major Organ Transplant, Except Lung Status Opportunistic Infections Bone/Joint/Muscle Infections/Necrosis Chronic Myeloid Leukemia Endocarditis Immune Disorders End-Stage Liver Disease Narcolepsy and Cataplexy Cystic Fibrosis Specified Hereditary Metabolic/Immune Disorders Morbid Obesity Psoriatic Arthropathy and Systemic Sclerosis 20. Non-Therapy Ancillary Component MDS Section I: Additional Active Diagnoses I8000.

9 Chronic Pancreatitis Inflammatory Bowel Disease Proliferated Diabetic Retinopathy and Vitreous Hemorrhage Complications of Specified Implanted Device or Graft Aseptic Necrosis of Bone Cardio-Respiratory Failure and Shock Myelodysplastic Syndrome and Myelofibrosis Systemic Lupus Erythematosus, other connective tissue disorders and Inflammatory Spondylopathies Diabetic Retinopathy Severe Skin Burns or Condition Intractable Epilepsy Disorders of Immunity (except RxCC97). Cirrhosis of Liver Respiratory Arrest Pulmonary Fibrosis and Other Chronic Lung Disorders 21.

10 Non-Case Mix Component This is a daily per diem flat rate and has not changed from the rate in RUGS IV. This payment is seen as payment for overhead costs such as laundry services, housekeeping, utilities, food, etc. 22. ICD-10 Coding New MDS item in Section I, I0020. Indicates the resident's primary medical condition that best describes the primary reason for admission Not to be confused with I8000. (see next slide). 23. ICD-10 Coding Additional Diagnosis I8000A. This is where we code the primary diagnosis in terms of an ICD-10 code for PDPM purposes 24.